Cromie et al: Occupational health and safety in physiotherapy: Guidelines for practice

Occupational health and safety in physiotherapy:

Guidelines for practice
Jean E Cromie, Valma J Robertson and Margaret O Best
La Trobe University, Melbourne

Most physiotherapists (91%) experience work related musculoskeletal disorders (WMSDs) at some time, and
one in six makes a career change as a consequence. Many of these disorders are attributed to manual
handling of patients. This paper proposes guidelines to reduce the risk of WMSDs based on Australian
legislative requirements, the results of a survey of Australian physiotherapists and the literature surrounding
injury prevention. These guidelines address the areas of environmental and job design, and the personal
physical capabilities of physiotherapists, within the context of law. The paper concludes by calling for further
research to explore and develop this area of injury prevention in the physiotherapy profession. [Cromie JE,
Robertson VJ and Best MO (2001): Occupational health and safety in physiotherapy: Guidelines for
practice. Australian Journal of Physiotherapy 47: 43-51]

Key words: Musculoskeletal System; Occupational Health; Risk Management;

Workers’ Compensation

Introduction controlling workplace hazards is outlined. The paper

Physiotherapists experience work related
musculoskeletal disorders (WMSDs) (Bork et al
1996, Cromie et al 2000, Holder et al 1999,
Mierzejewski and Kumar 1997, Molumphy et al
1985, Scholey and Hair 1989) of sufficient severity
that one in six make career changes as a consequence
(Cromie et al 2000). Musculoskeletal injury is
frequently associated with manual handling (Burdorf
and Sorock 1997), defined as “any activity requiring
the use of force exerted by a person to lift, push, pull,
carry or otherwise move, hold or restrain … an
animate or inanimate object” (Manual Handling
Regulations 1999). Although physiotherapists
frequently need to use manual handling and awkward
postures in the course of their work (Ellis 1993,
Fenety 1992, Hignett 1995), there are no profession-
specific guidelines to assist them. As the coming
decade is designated the decade for the prevention
and treatment of musculoskeletal disorders (Garfin et
al 1999), it is timely for physiotherapists to consider
preventive measures they might implement to reduce
their own WMSDs.
then proposes guidelines to reduce the risk of
WMSDs within the framework of the legislative
requirements. The proposed guidelines are presented
in Italics, and each is followed by a justification using
findings from a 1997 survey of Victorian
physiotherapists (Cromie et al 2000) and other
published literature documenting injury prevention in
both the physiotherapy profession and other
industries.
Legislation Occupational health and safety
legislation provides a framework to ensure that all
parties in the employment agreement (employer,
employee) meet minimum standards for injury
prevention. The law may then be interpreted into a
practical document providing industry guidelines,
such as codes of practice. Individual industries or
occupational groups may then explicate the law and
code of practice to provide guidelines specific to the
work context of that industry or occupation. These are
all external controls aimed at reducing injury by
influencing job design and workers’ behaviour at a
macro level.

The first part of this paper outlines the legislative In Australia, occupational health and safety
framework in which occupational health and safety legislation and resulting codes and standards state that
issues in Australian physiotherapy practice are to be the employer has a duty of care to their employees to
considered. The risk management approach to provide a safe workplace (NOHSC 1999). Laws about

Australian Journal of Physiotherapy 2001 Vol. 47 43

Cromie et al: Occupational health and safety in physiotherapy: Guidelines for practice
occupational health and safety are the responsibility
of each state or territory government, and may differ
between jurisdictions. However, all Australian
legislation is based on a risk management model in
which a hierarchy of control prescribes hazard
identification, risk assessment, risk control and
review.
Hazard identification Hazard identification involves
identifying situations or events which could harm
people in the workplace. The hazard may be
environmental or relate to particular tasks, activities
or systems of work. Checklists, workplace
inspections, injury records and consultation with
workers are all sources of information to assist with
hazard identification.
Risk assessment Once a hazard is identified, risk
assessment is required to determine the likelihood of
the injury and the consequences of its occurrence.
Risk assessment for manual handling should
incorporate a consideration of the postures,
movements, forces exerted, environmental conditions
and the duration and frequency of the task (Manual
Handling Regulations 1999).
Risk control The aim of risk control is to eliminate
the hazard or, if that is not possible, to minimise the
likelihood of harm. The preferred option is to change
the environment, rather than the people working in it.
Control of manual handling risks is implemented by:
• introducing design changes to eliminate the risk;
• reducing the risk where design changes are not
possible (including introducing breaks, pacing
and scheduling);
• changing the objects used in the manual handling
task;
• using mechanical aids where removing the risk is
not possible when none of the previous strategies
are practicable; and
• providing training in performance of work to
minimise the risk of injury.
Legislation and codes of practice require employers to
undertake risk assessment and implement risk control
measures. They are explicitly framed to ensure that
training and education are implemented only after the
work environment and work systems have been
44
modified, the objects changed and mechanical aids
introduced (Manual Handling Regulations 1999,
Regulation 15.2).
Review The final step in the systematic approach to
risk management is to review the effectiveness of the
implemented control measures, and ensure that no
new risks have been introduced as a consequence.
Injury statistics need to be monitored following the
introduction of risk control measures, to determine
whether the controls have indeed reduced the injury
rates. The process of risk management is continuous.
Hazard identification and risk assessment must be
carried out whenever circumstances change and
suitable control measures should then be
implemented (Manual Handling Regulations 1999).
Industry standards and physiotherapy The Victorian
WorkCover Authority (VWA) has published a
document advising on the design of workplaces where
patients are handled (Victorian WorkCover Authority
1999), with a particular emphasis on spatial
requirements. Australian Standards provide for the
selection and use of mechanical aids for patient lifting
and moving (AS2569.2), however no standards are
available regarding optimal workplace design for
therapists engaged in manual therapy, nor are there
suggested workloads for physiotherapists.
Proposed guidelines
The remainder of this paper proposes guidelines for
physiotherapy practice and provides justification by
referring to the legislation and relevant literature.
1. All physiotherapists must familiarise themselves
with requirements of the legislation governing
occupational health and safety (and in particular
manual handling) in their jurisdiction. As a
minimum, they should know the principles of risk
management, and be able to apply hazard
identification, risk assessment, control and
review in their workplace.
Occupational health and safety legislation provides a
framework to ensure that all parties in the
employment agreement (employer, employee,
designers) meet minimum standards for injury
prevention. The primary justification for Guideline 1
is the law itself. The National Occupational Health
and Safety Commission emphasises the obligation of
Australian Journal of Physiotherapy 2001 Vol. 47
 Cromie et al: Occupational health and safety in physiotherapy: Guidelines for practice
employers and employees to comply with relevant
state or territory law, and the duty of care for
employers to provide a safe place of work for
employees (National Occupational Health and Safety
Commission 1999). The assumption underlying the
legislative requirements is that it is the job, rather than
inadequacies on the part of the worker, that
contributes to injury. If this assumption is true,
modification of the job and the physical demands of
the job will act to reduce the risk of injury. The
occupational health laws vary between states, but all
advise changes in job design ahead of training
(Manual Handling Regulations 1999, National
Occupational Health and Safety Commission 1990).
The second justification for Guideline 1, in the
absence of objective scientific proof of the
effectiveness of injury prevention strategies, is to
offer a defensible rationale for preventive measures.
Cromie et al (2000) reported a discrepancy between
the risk factors therapists identified as contributing to
their WMSDs and the self-protective strategies they
most commonly reported using. More than 50% of
the therapists who used manual orthopaedic
techniques identified their use as making a major
contribution to their WMSDs and more than 50% (to
whom it was relevant) specified performing the same
task repeatedly as contributing significantly to
WMSDs. In spite of this, the majority of self
protective strategies these therapists reported using
related to postural factors, such as adjusting the
height of the work surface and modifying patient or
therapist position. This discrepancy suggests that
therapists need to consider a risk management
approach to identify hazards and address risk factors
specific to their work.
2. The majority of physiotherapists experience
WMSDs. The low back, neck, upper back and
upper limbs are most vulnerable to injury, and
therapists must identify factors in the workplace,
and away from work, that increase risk of injury
to these areas.
In order to implement the risk management model of
hazard identification, risk assessment, risk control
and review, it is helpful to understand the common
injuries experienced by therapists, and the risks to
which they are exposed. Indeed, these data are
frequently used in the preliminary step of hazard
identification.
Australian Journal of Physiotherapy 2001 Vol. 47
In the study of Victorian therapists reported by
Cromie et al (2000) most physiotherapists (91%)
experienced WMSDs at some time, and one in six
therapists was forced to make career changes as a
consequence. Therapists in this study identified
performing manual techniques and lifting or
transferring patients as contributing to WMSDs,
suggesting formal risk assessment and management
of these activities is appropriate (Manual Handling
Regulations 1999).
Cromie et al’s (2000) study found that the body area
with the highest annual prevalence of WMSDs was
the low back (63%), followed by neck (48%), and
upper back (41%). Thumb (34%), shoulder (23%) and
wrist and hand (22%) WMSDs were also prevalent.
The researchers found that therapists who performed
manual therapy, performed the same task repeatedly,
saw many patients in one day and who did not have
enough rest breaks were at increased risk of neck and
upper limb injuries (including thumb). Thumb
symptoms in particular were related to performing
manipulation and mobilisation techniques, with the
prevalence of symptoms increasing as the number of
hours performing these techniques increased. Postural
risk factors and moving or transferring patients were
associated with an increased risk of spinal (neck,
upper and lower back) symptoms (Cromie et al 2000).
These areas of the body and their associated risk
factors provide a basis for risk assessment in the
context of physiotherapy work.
Postural factors (particularly in conjunction with
heavy loading) are recognised as potentially harmful
to physiotherapists (Ellis 1993, Fenety 1992, Hignett
1995, Robertson et al 1993). Therapists’ posture can
be constrained by anthropometric dimensions or the
need to use a technique requiring them to assume
harmful postures (Hignett 1995). Other studies have
identified repeated muscle contractions and static
loading as risk factors in the development of WMSDs
(Kilbom 1994b, Roquelaure et al 1997).
These risk factors, and the common WMSDs
experienced by physiotherapists, suggest risk
assessment should consider not only the postural and
patient handling demands, but also risk factors
associated with manual therapy, such as repetitiveness
of the work, caseload and work organisation.
Risk control Legislation requires an employer to
eliminate risk and, if that is not practicable, to reduce
45
Cromie et al: Occupational health and safety in physiotherapy: Guidelines for practice
it as far as is practicable (Manual Handling
Regulations 1999, Regulation 15.1).
Where risk cannot be eliminated, physiotherapists
must minimise risk by altering the workplace.
3. Established ergonomic guidelines for space,
equipment, furniture and environmental
conditions should be mandatory in the design of
physiotherapy workplaces.
Design of the physical environment is an important
consideration in the prevention of WMSDs.
Elimination of extreme postures and force, or
prolonged static postures, should be considered when
designing the physical environment, as should space
and lighting. Prolonged or repeated bending is
recognised as increasing the risk of back problems
(Burdorf and Sorock 1997), and provides a rationale
for using a height and angle-adjustable work surface.
While most therapists would be aware of the
usefulness and benefit of an adjustable treatment
plinth in the physiotherapy workplace, it is not a
requirement, even when multiple therapists (with
different anthropometric dimensions) are using the
same facilities. Patient handling with assistance is
less risky than handling by only one person
(Robertson et al 1993), but presumes an adequate
availability of staff. This factor needs to be considered
by physiotherapy managers and others representing
the interests of therapists.
Changing the physical equipment used by workers
can reduce the amount of time spent in awkward
postures (Keyserling et al 1993), a known risk factor
in the development of WMSDs of the upper limb
(Silverstein et al 1986). This suggests that the
principle of environmental design may be effective in
reducing upper limb injury as well as low back injury.
Many of the known ergonomic risks associated with
posture and exertion are taught to student
physiotherapists as part of a musculoskeletal
physiotherapy program. However, students may see
these principles as applying only to patients, rather
than themselves. Possibly a more explicit
consideration of the relevance of this information to
the practice of physiotherapy at a student level would
ensure that therapists consider these issues in the
context of their own work. Development of design
guidelines specific to physiotherapy practice should
incorporate principles of injury prevention.
46
4. The physiotherapist’s job must be designed to
ensure variety in the physical demands of work.
This may be done by:
• scheduling different activities throughout
the working day and week, and by including
a variety of techniques and treatment
options into therapy sessions;
• scheduling adequate and regular rest breaks
involving a change in posture as well as
activity level;
• seeing a range of clients with various
conditions;
• participating in policy development in
health care to ensure reasonable workloads
and adequate work environments; and
• increasing the range of treatment techniques
at the therapist’s disposal, aiming for variety
in physical demands.
Existing guidelines for the prevention of WMSDs
advocate optimum workplace design in accordance
with established ergonomic principles, time limits for
exposure to risk factors and reduction of extreme
exposure. Winkel and Westgaard (1992) proposed
guidelines for the prevention of neck and shoulder
injuries, suggesting the introduction of new work
tasks with differing physical demands as a way of
reducing exposure to risk. Kilbom (1994a), in her
recommendations for the performance of repetitive
work, proposed interventions against the following
risk factors: extreme postures and static work; lack of
control; other risk factors such as lack of skill; high
output demands; and monotony. She suggested
interventions should be prioritised in the same order
and could include work station and tool re-design,
work re-organisation and training.
Guidelines for work and rest times are based on the
assumption that fatigue is a precursor to injury, and
that allowing the body to recover from fatigue reduces
the risk of injury (Konz 1998a and 1998b). However,
this has not been established by research findings
(Viikari-Juntura 1997).
In terms of job design, there are no standards
available stipulating workloads for physiotherapy
treatment. While there is evidence that therapists
modify their position relative to the patient where
Australian Journal of Physiotherapy 2001 Vol. 47
 Cromie et al: Occupational health and safety in physiotherapy: Guidelines for practice
possible (Cromie et al 2000), other aspects of their
work, such as scheduling, number of patients, rest
breaks and variety in work have not been addressed.
Although Fenety and Kumar’s (1992) study did not
use symptoms of WMSD as an outcome measure,
their intervention dealing with workloads improved
productivity and made workloads more manageable.
Repeated muscle contractions and static loading are
known to be risk factors in the development of
cumulative trauma disorders (Kilbom 1994b,
Roquelaure et al 1997). Variety in work and breaks in
repetitive or prolonged static activities are
recommended to prevent these injuries (Kroemer
1989). Job rotation, rest breaks and variety in work
can be integrated into the physiotherapist’s job to
avoid overloading any particular anatomical area
either by sustained posture or repetitive actions. The
implication for physiotherapists is that they should
ensure variety in their techniques, in order to vary the
stresses placed on a range of anatomical areas.
Cromie et al (2000) suggested a need for therapists to
have at their disposal a variety of treatment tools, to
enable them to vary the physical demands on their
bodies.
Scheduling variety into tasks, and organising the
work to maximise efficiency, may provide a way of
reducing risks associated with poor work flow. While
manual orthopaedic techniques cannot always be
eliminated (or engineered out) from the job, they may
be reduced or modified while still achieving
treatment goals. Mechanical aids may provide an
appropriate solution in some instances.
Cromie et al (2000) found that Victorian
physiotherapists used self-protective strategies to
reduce the strain on their bodies while working. Most
modified their patient’s or their own position or
adjusted the treatment plinth height. By contrast, a
minority interrupted their work to alter their posture,
or stopped a treatment that was causing symptoms.
Almost half (42%) of the respondents who used
manual techniques reported using a different part of
the body to administer a manual technique.
Although workload issues were significantly
represented as being associated with WMSDs in the
neck and upper limbs, Cromie et al (2000) found only
one self-protective strategy addressed this area. This
strategy was to select techniques that would not
aggravate symptoms, and was used by 40% of
respondents concerned.
Australian Journal of Physiotherapy 2001 Vol. 47
5. Mechanical aids and equipment should be used
whenever appropriate. Therapists must be
trained in their use.
Cromie et al (2000) reported that more than 90% of
therapists used some type of assistive device to
reduce the strain on their bodies. These included
adjustable work surfaces, “wheelie” stools, slide
boards, lifting belts, splints and unspecified “other”.
Although commercial literature and catalogues
provide evidence that physiotherapists probably use a
variety of aids and equipment, their ubiquity is
unknown. Aids and equipment alone, without training
in their proper use, are unlikely to be effective in
reducing the risk of injury. Training in risk
minimisation, and the use of aids and equipment,
should be ongoing and incorporated into both pre-
clinical and continuing professional education.
6. Training must not be the sole or primary means
of controlling risk. Training in injury prevention
must contain the risk management model of
controlling risk, and include ‘in principle’
preventive measures rather than training in
specific methods or techniques.
The term “training” is used in the literature to mean a
program designed to address perceived deficiencies
in knowledge, physical ability, or both. Education as
a means of reducing injury assumes that the cause of
injury is that workers are unaware of the correct way
of doing things, and are therefore injured because of
ignorance.
The prevalence of work related musculoskeletal
disorders among physiotherapists is evidence that
their education about injury, its causes and
mechanisms does not prevent injury (Bork et al 1996,
Cromie et al 2000, Holder et al 1999, Mierzejewski
and Kumar 1997, Molumphy et al 1985, Scholey and
Hair 1989). Stubbs et al (1983) commented, “If the
work is intrinsically unsafe, then no amount of
training can correct the situation” (p. 777), and
concluded by recommending the development of safe
systems of work (work design).
Education in manual handling as a means of reducing
the risk of low back injury has been used extensively
by industries ranging from health care to
manufacturing. Back schools have advocated
47
Cromie et al: Occupational health and safety in physiotherapy: Guidelines for practice
education as a means of injury prevention for many
years. In most cases they have aimed to prevent
recurrence once injury has occurred (secondary
prevention). Studies of the effectiveness of these
schools typically demonstrated increased knowledge
of back injury among participants, but little or no
reduction in injury rates. Linton and Kamwendo
(1987) reviewed 16 studies on the effectiveness of
back schools. At that time, they concluded that little
empirical evidence existed that low back school
improved either behaviour or symptoms. More than a
decade later, the evidence does not appear to have
changed their conclusion (Daltroy et al 1997, Straker
1999b). There is some evidence that workers do not
always implement the methods they have been taught
(St-Vincent et al 1987), which may partially explain
why the demonstrated increase in knowledge does not
necessarily mean improvement in behaviour and
symptoms. Both physiotherapy and industry assume
that improved knowledge will result in a
commensurate reduction in the rate or severity of
injury. In the light of the available studies, this
assumption is probably not justifiable, and certainly
does not vindicate education as the only injury
prevention strategy.
The assumption that correct patient handling
effectively prevents WMSDs is exemplified by the
use of the adjective “proper” to describe lifting or
patient handling techniques (Mierzejewski and
Kumar 1997, Molumphy et al 1985). This supposition
operates widely in the area of manual handling, where
physiotherapists are frequently called on to provide
training in “proper” or “safe” techniques. (The
unstated assumption is that proper performance of the
lifting task will prevent injury.) However, there are
several schools of thought as to what this “proper”
technique might be. Garg (1993) observed that there
was no concrete evidence supporting one method as
safer than the others. Squat, stoop, freestyle and semi-
squat lifting techniques all have their advocates
(Straker 1999a). Straker suggested that rather than
teaching a particular technique, principles to reduce
the risk of injury should be taught. This approach is
appropriate to physiotherapy, where there is much
variability in the capabilities and needs of patients
and in the tasks undertaken by therapists (Manual
Handling Regulations 1999).
7. Risk assessment and control must be ongoing.
Once implemented, these guidelines must be
examined for their effectiveness, and modified
where necessary. Risk management and review
48
must be carried out at both an individual and
institutional level.
Work related musculoskeletal disorders should be
documented prior to, and following, implementation
of these guidelines. A minority of therapists claim
workers’ compensation (Cromie et al 2000), so
alternative measures such as lost time, or symptom
surveys, should be utilised to monitor the
effectiveness of any changes that are implemented.
The requirement for risk assessment and control to be
reviewed and updated is written into law (Manual
Handling Regulations 1999, Regulation 14.3). Hazard
identification must be applied whenever a task is
undertaken for the first time and again before any
alteration is made to objects used in the workplace, or
an object used for another purpose. Hazard
identification is also required if new information
about manual handling is made available to the
employer or if a musculoskeletal disorder is reported
by or on behalf of an employee (Regulation 13.3; a-e).
8. Prospective physiotherapists must recognise the
physical demands and constraints of the job.
Students and qualified physiotherapists need to
choose career paths congruent with their
physical abilities. Physiotherapists should
maintain an appropriate level of personal fitness
for their work.
As opposed to training to address perceived
deficiencies in knowledge, physical training assumes
the cause of injury to be a mismatch between the
physical capacity of the worker and the requirements
of the job. The training program targets deficiencies
in the individual to reduce the discrepancy. This
guideline addresses the issue of a mismatch between
the physical capability of the physiotherapist and the
physical demands of the job.
Selection to prevent injury assumes that some
workers are more at risk than others due to prior
history, fitness or physical ability. It is based on
knowledge of the demands of the job, and excludes
workers deemed to be at high risk of injury, to ensure
that only individuals with a low risk are selected for
the job.
The basis for screening in this way is work done by
Keyserling et al (1980) who found that when the
demands of the job exceeded the capacity of the
Australian Journal of Physiotherapy 2001 Vol. 47
 Cromie et al: Occupational health and safety in physiotherapy: Guidelines for practice
workers, they experienced significantly higher injury
rates. There is some conflict in the findings of
prospective studies using selection as a preventive
strategy (Bigos et al 1992, Reimer et al 1994,
Smedley et al 1997), with one (Bigos et al) suggesting
that pre-employment screening is ineffective in
predicting back injury, and the other two suggesting
that screening may be useful in prevention.
The literature gives no indication that
physiotherapists are selected for a particular job using
any physical capacity criteria. Physiotherapists in
Australia must meet certain competencies (implying
some degree of physical ability) and be registered
with a state based registration board in order to
practise (Physiotherapists Registration Act 1998).
However, there are many areas in which therapists
may practise, making it feasible for therapists with
differing physical abilities to choose to work within
their capability.
Refusing employment to a worker on the basis of their
physical capabilities (or any other attribute) is
unlawful, unless the attribute is a necessary
requirement of the job (Disability Discrimination Act
1992, Equal Opportunity Act 1995). As determination
of physical job requirements can be complex, this
strategy may prove hard to implement. However, it
might be appropriate to document the physical
demands of different areas of physiotherapy, so
enabling therapists to make an informed choice based
on their physical abilities.
Exercise Another way of addressing a mismatch
between capacity and job demands is to improve work
tolerance and manual handling capacity (Genaidy and
Karwowski 1992) using exercise. Improving strength
has been shown to decrease the duration of low back
symptoms or days lost from work due to back pain
(Gundewall et al 1993, Kellett et al 1991), but
methodological issues reduce the possibility of
drawing conclusions from these studies. For example,
Gundewall et al (1993) allowed their intervention
group access to physiotherapy advice, making it
difficult to determine the cause of the improvement,
and Kellett et al (1991) only investigated factory
workers with back pain, making the preventive
benefits for those without back pain uncertain.
In their study of Californian physical therapists,
Molumphy et al (1985) reported that 21% of
Australian Journal of Physiotherapy 2001 Vol. 47
therapists with subsequent LBP performed back
flexibility exercises prior to being injured, and
significantly more (61%) did so after being injured.
This suggests that at least some of the therapists who
were subsequently injured were aware of a
predisposition to injury, prompting an exercise
program, but there was no indication of how
widespread exercise was as a preventive strategy
among all therapists.
Exercise may offer a way for physiotherapists to
reduce the rate and severity of WMSDs in practice.
However, this may not be formally recognised by
educators or professional associations. An emphasis
on fitness at an undergraduate level, and an ongoing
commitment to fitness, may be important strategies to
reduce injury in the long term. Pause gymnastics,
warming up, resting and changes in posture also are
other forms of exercise. Further research is needed to
determine the effectiveness of exercise as a preventive
strategy.
Limitations Physiotherapy, as a job, can be broadly
defined. Therefore these guidelines are qualitative in
nature, and to be interpreted by individuals for
specific situations. Their qualitative nature means
they are responsive and flexible in a variety of
situations (Kuorinka 1998). Kuorinka suggests that
such guidelines should be procedural, and address
multiple criteria. They should be feasible to execute,
and once implemented, their effects on work related
musculoskeletal disorders (WMSDs) should be
assessed (Viikari-Juntura 1997). Development of
guidelines should be based on existing knowledge, or
be evidence-based (Kuorinka 1998, Viikari-Juntura
1997). Although the existing literature is not
extensive, it forms the basis for the guidelines
proposed here.
Further research Research is needed to document
the physical requirements of physiotherapy, to
establish safe work practices with respect to patient
workload, scheduling and work/rest ratios.
These guidelines for physiotherapy practice are
proposals. As such, they are untested, and will require
refinement and modification as the available body of
knowledge increases.
49
Cromie et al: Occupational health and safety in physiotherapy: Guidelines for practice
Conclusion
These proposed guidelines address the areas of
postural and environmental risk factors, within the
framework of occupational health and safety
legislation. They acknowledge the need for
compliance with established ergonomic guidelines in
the design of the working environment, and the job
and systems of work. The guidelines affirm the need
for involvement in policy decisions, as they influence
the occupational health and safety of
physiotherapists. Finally, the proposed guidelines
recognise the developing state of knowledge and the
need for ongoing research and development.
Acknowledgement The survey referred to in this
paper was financially supported by an APA Victorian
Branch Research Grant.
Authors Jean Cromie, School of Physiotherapy, La
Trobe University, Bundoora, Victoria 3083. E-mail:
jean@osa.com (for correspondence). Val Robertson,
School of Physiotherapy, La Trobe University,
Bundoora, Victoria 3083. Margaret Best, School of
Physiotherapy, La Trobe University, Bundoora,
Victoria 3086.
References
Bigos SJ, Battié MC, Fisher LD, Hanson TH, Spengler DM
and Nachemson AL (1992): A prospective evaluation of
preemployment screening methods for acute industrial
back pain. Spine 17: 922-926.
Bork BE, Cook TM, Rosecrance JC, Engelhardt KA,
Thomason M-EJ, Wauford IJ and Worley RK (1996):
Work-related musculoskeletal disorders among physical
therapists. Physical Therapy 76: 827-835.
Burdorf A and Sorock G (1997): Positive and negative
evidence of risk factors for back disorders. Scandinavian
Journal of Work, Environment and Health 23: 243-256.
Cromie JE, Robertson VJ and Best MO (2000): Work-
related musculoskeletal disorders in physical therapists:
prevalence, severity, risks and responses. Physical
Therapy 80: 336-351.
Daltroy LH, Iversen MD, Larson MG, Lew R, Wright E, Ryan
J, Zwerling C, Fossel AH and Liang MH (1997): A
controlled trial of an educational program to prevent low
back injuries. New England Journal of Medicine
337: 322-328.
Disability Discrimination Act (1992): Canberra: Australian
Government Publishing Service.
Ellis BE (1993): Moving and handling patients: An
evaluation of current training for physiotherapy students.
Physiotherapy 79: 323-326.
50
Equal Opportunity Act (1995): Melbourne: Information
Victoria, State Government Bookshop.
Fenety A (1992): Compression loads on a physical
therapist’s lumbar spine during selected treatment tasks.
Proceedings of Advances in Industrial Ergonomics and
Safety IV. Denver, Colorado.
Garfin SR, Andersson G, Gronblad M and Rydevik B
(1999): The bone and joint decade 2000-2010, for
prevention and treatment of musculoskeletal disorders.
Spine 24: 1055-1057.
Garg A (1993): What basis exists for training workers in
“correct” lifting technique? Proceedings of the
International Ergonomics Association World Conference:
The Ergonomics of Manual Work. Warsaw, Poland.
Genaidy AM and Karwowski W (1992): Physical training: A
tool for increasing work tolerance limits of employees
engaged in manual handling tasks. Ergonomics
35: 1081-1102.
Gundewall B, Liljeqvist M and Hansson T (1993): Primary
prevention of back symptoms and absence from work: A
prospective randomised study among hospital
employees. Spine 18: 587-594.
Hignett S (1995): Fitting the work to the physiotherapist.
Physiotherapy 81: 549-552.
Holder NL, Clark HA, DiBlasio JM, Hughes CL, Scherpf JW,
Harding L and Shepard KF (1999): Cause, prevalence,
and response to occupational musculoskeletal injuries
reported by physical therapists and physical therapist
assistants. Physical Therapy 79: 642-652.
Kellett KM, Kellett DA and Nordholm LA (1991): Effects of
an exercise program on sick leave due to back pain.
Physical Therapy 71: 283-291.
Keyserling WM, Brouwer M and Silverstein BA (1993): The
effectiveness of a joint labor-management program in
controlling awkward postures of the trunk, neck, and
shoulders: results of a field study. International Journal of
Industrial Ergonomics 11: 51-65.
Keyserling WM, Chaffin DB and Parks KS (1980):
Establishing an industrial strength testing program.
American Hygiene Association Journal 41: 730-736.
Kilbom Å (1994a): Repetitive work of the upper extremity:
Part l - Guidelines for the practitioner. International
Journal of Industrial Ergonomics 14: 51-57.
Kilbom Å (1994b): Repetitive work of the upper extremity:
Part II - The scientific basis (knowledge base) for the
guide. International Journal of Industrial Ergonomics
14: 59-86.
Konz S (1998a): Work/rest: Part I - Guidelines for the
practitioner. International Journal of Industrial
Ergonomics 22: 67-71.
Konz S (1998b): Work/rest: Part II - The scientific basis
(knowledge base) for the guide. International Journal of
Industrial Ergonomics 22: 73-99.
Kroemer KHE (1989): Cumulative trauma disorders: their
recognition and ergonomics measures to avoid them.
Applied Ergonomics 20: 274-280.
Kuorinka I (1998): Prevention of work-related
musculoskeletal disorders in the workplace. International
Journal of Industrial Ergonomics 21: 1-3.
Australian Journal of Physiotherapy 2001 Vol. 47
 Cromie et al: Occupational health and safety in physiotherapy: Guidelines for practice
Linton SJ and Kamwendo K (1987): Low back schools:
A critical review. Physical Therapy 67: 1375-1383.
Manual Handling Regulations (1999): Melbourne:
Information Victoria, State Government Bookshop.
Mierzejewski M and Kumar S (1997): Prevalence of low
back pain among physical therapists in Edmonton,
Canada. Disability and Rehabilitation 19: 309-317.
Molumphy M, Unger B, Jensen GM and Lopopolo RB
(1985): Incidence of work-related low back pain in
physical therapists. Physical Therapy 65: 482-486.
National Occupational Health and Safety Commission
(1990): Manual Handling; National Standard for Manual
Handling (NOHSC: 1001); National Code of Practice for
Manual Handling (NOHSC: 2005). Canberra: Australian
Government Publishing Service.
National Occupational Health and Safety Commission
(1999): Occupational Health and Safety in Australia.
Available at: http://www.worksafe.gov.au/work/regulatory/
legalobligations_index.htm. Accessed November 17
1999.
Physiotherapists Registration Act (1998): Melbourne:
Information Victoria, State Government Bookshop.
Reimer DS, Halbrook BD, Dreyfuss PH and Tibiletti C
(1994): A novel approach to preemployment worker
fitness evaluations in a material-handling industry. Spine
19: 2026-2032.
Robertson LD, Changsut R, Ramos LS and Jones DW
(1993): Influence of job and personal risk factors on
safety limits for kinesiotherapists performing a stressful
clinical lifting task. Clinical Kinesiology Spring: 7-16.
Roquelaure Y, Mechali S, Dano C, Fanello S, Benetti F,
Bureau D, Mariel J, Martin Y-H, Derriennic F and
Penneau-Fontbonne D (1997): Occupational and
Australian Journal of Physiotherapy 2001 Vol. 47
personal risk factors for carpal tunnel syndrome in
industrial workers. Scandinavian Journal of Work,
Environment and Health 23: 364-369.
Scholey M and Hair M (1989): Back pain in physiotherapists
involved in back care education. Ergonomics 32: 179-190.
Silverstein BA, Fine LJ and Armstrong TJ (1986): Hand
wrist cumulative trauma disorders in industry. British
Journal of Industrial Medicine 43: 779-784.
Smedley J, Egger P, Cooper C and Coggon D (1997):
Prospective cohort study of predictors of incident low
back pain in nurses. British Medical Journal 314: 1225-
1228.
Straker L (1999a): Lifting technique. In Mital A, Ayoub M,
Kumar S, Wang MJ and Landau K (Eds): Industrial and
Occupational Ergonomics: User’s Encyclopedia .
Cincinatti: CD-ROM.
Straker L (1999b): Preventing work-related back pain.
Proceedings of Moving In On Occupational Injury
Conference. Cairns.
St-Vincent M, Lortie M and Tellier C (1987): Training in safe
lifting: Are the methods taught used by workers? In
Buckle P (Ed.): Musculoskeletal Disorders at Work.
London: Taylor and Francis, pp. 159-164.
Viikari-Juntura ERA (1997): The scientific basis for making
guidelines and standards to prevent work-related
musculoskeletal disorders. Ergonomics 40: 1097-1117.
Victorian WorkCover Authority (1999): Designing
Workplaces for Safer Handling of Patients/Residents
(Guidelines). Melbourne: Victorian WorkCover Authority.
Winkel J and Westgaard R (1992): Occupational and
individual risk factors for shoulder-neck complaints: Part I
- Guidelines for the practitioner. International Journal of
Occupational Ergonomics 10: 79-83.
51